Health inspection·October 19, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide eating assistance in a dignified manner for 4 of 4 sampled residents observed for in-room dining, Residents #3, #9, #25 and #53. The findings included: Review of the facility's policy titled Activities of Daily Living effective date 04/01/22 documents a resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition . 1) Review of Resident #3's clinical record documented an admission on [DATE] and a readmission on [DATE]. The resident diagnoses included Dysphagia (difficulty swallowing) Heart Disease, Severe Protein-Calorie Malnutrition, Muscle Wasting and Depression. Review of Resident #3's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 10 indicating that the resident had moderate cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance to total assistance from the staff to complete the activities of daily living (ADL). Review of Resident #3's care plan titled ADL Self-care performance deficits . initiated on 10/13/23 documented an intervention dated 10/13/23 that read .provide up to substantial/max assist with eating . On 10/18/23 at 12:01 PM, observation revealed Resident #3's lunch tray on top of the table and no nursing staff in the room. Further observation revealed Staff Q, Certified Nursing Assistant passing lunch tray to other residents in the same hallway. Consequently, an interview was conducted with Staff Q who stated she was the only staff passing trays for the residents in the 400 and part of the 500 hall. The 400 hall had 10 residents and the 500 hall had 11 residents. Staff Q stated she had three of ten residents that needed to be fed. On 10/18/23 observation from 12:02 PM to 12:35 PM, revealed Staff Q the only staff attending residents during lunch time. On 10/18/23 at 12:35 PM, observation revealed Staff Q, CNA feeding Resident #3. Staff Q was observed standing while feeding the resident. Subsequently, an interview was conducted with Staff Q who stated she sometimes sits down to feed the resident but that she had three to feed today. She stated she was supposed to sit down while feeding the resident and proceeded to sit in the chair available in Page 1 of 28 105852 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0550 the room. Level of Harm - Minimal harm or potential for actual harm 2) Review of Resident #9's clinical record documented an admission on [DATE] and a readmission on [DATE]. The resident diagnoses included Pyogenic Arthritis, Macular Degeneration, Muscle Wasting and Atrophy, and Major Depressive Disorder. Residents Affected - Few Review of Resident #9's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 15, indicating that the resident had no cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance to total assistance from the staff to complete the activities of daily living (ADL). Review of Resident #9's care plan titled ADL Self-care deficit related to physical limitations, finger contractures, weakness initiated on 10/25/2021 and revised on 09/08/23 documented an intervention initiated on 06/30/22 that read .needs assistance with eating, deliver meal tray & assist with tray set up/eating as needed. On 10/16/23 at 12:33 PM, observation revealed Resident #9 in bed and been fed by Staff Q, CNA. Staff Q was standing while feeding the resident. On 10/18/23 at 12:20 PM, observation revealed Resident #9's lunch tray on top of the table and no nursing staff noted in the room. The resident was unable to reach the tray and eat by himself. On 10/18/23 at 12:35 PM, an interview was conducted with Staff Q, CNA who stated that Resident #9 needs to be fed and that she will feed him as soon as she finish feeding Resident #3. On 10/18/23 at 12:40 PM, an interview was conducted with Staff D, Registered Nurse (RN) who stated she did not know if the CNA were supposed to be sitting or standing while feeding a resident. Staff D was asked if she was aware that Staff Q had 3 residents to be fed and that Resident #9 had not eaten yet. Staff D replied she was not aware and added that the CNAs were supposed to ask for help. Staff D was asked who was supposed to assist the resident with their meals and stated all CNAs were to assist with feeding the residents. On 10/18/23 at 12:45 PM, observation revealed Staff Q, CNA entering Resident #9's room. Consequently, an interview was conducted with Staff Q who stated she just started to feed Resident #9. Staff Q was apprised that the resident waited 45 minutes to be fed. Staff Q stated she guessed everyone was busy. 3) Review of Resident #25, clinical record documented an admission on [DATE] and a readmission on [DATE]. The resident diagnoses included Chronic Kidney Disease, Dementia, and Legal Blindness. Review of Resident #25's MDS quarterly assessment dated [DATE] documented a BIMS score of 11 indicating that the resident had moderate cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance to total assistance from the staff to complete the activities of daily living. Review of Resident #25's care plan titled ADL Self-care deficit related to disease process initiated on 11/24/2021 and revised on 09/07/23 documented an intervention that read .is able to feed herself, deliver meal tray & assist with tray set up as needed .' 105852 Page 2 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/16/23 at 12:27 PM, observation revealed Resident #25 in bed and been fed by Staff R, CNA. An interview was conducted with Staff R who stated that she had to feed the resident because the resident was blind and gets the food all over herself making a mess. Observation revealed Staff R was standing while feeding the resident. On 10/16/23 at 5:52 PM, evening dining observation revealed Resident #25 in bed and been fed by Staff R, CNA. The CNA was observed standing while feeding the resident. Further observation revealed a chair next to the resident bed in front of the CNA was available. On 10/19/23 at 4:31 PM, during an interview, the Director of Nursing (DON) was apprised of the findings. The DON stated that staff was supposed to seat down while feeding the residents and added that there was a chair available in the residents room. 4. Review of the facility's policy titled Resident's Rights dated 04/01/22 showed that Residents have the right to respect and dignity. Resident #53 was admitted to the facility on [DATE] with diagnoses of Dementia, Kidney Disease, and Muscle wasting. The Quarterly Minimum Data Set, dated [DATE] showed a Brief Interview of Mental Status (BIMS) that the resident is severely cognitively impaired. In an observation conducted on 10/16/23 at 5:45 PM, Resident #53's dinner tray entered the room. Continued observation showed Staff B, a Certified Nursing Assistant, standing over Resident #53, assisting him with the dinner meal. In this observation, Staff B referred to Resident #53 as Feeder when asked by the Surveyor if Resident #53 needed help with his meals. The care plan initiated on 06/12/23 revealed that Resident #53 has a self-care deficit related to diseased processes. He needs assistance with eating, delivery of meal trays, tray set up, and eating as needed. In an interview conducted on 10/19/23 at 9:50 AM, Staff K, Certified Nursing Assistant, stated that she helps any residents who need assistance with their meals. She further said that she would elevate the head of the bed before assisting the residents with their meal, take a chair, and sit down near the residents. When asked why she sits down, she said, You are not supposed to stand while feeding residents. In an interview conducted on 10/19/23 at 3:00 PM with the facility's Administrator, she was told of the findings. 105852 Page 3 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to provide fingernails grooming for 2 of 2 sampled residents, Residents #9 and #53, observed for nail grooming. Residents Affected - Few The findings included: Review of the facility's policy titled Activities of Daily Living effective date 04/01/22 documents a resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good .grooming . 1) Review of Resident #9's clinical record documented an admission on [DATE] and a readmission on [DATE]. The resident diagnoses included Pyogenic Arthritis, Macular Degeneration, Muscle Wasting and Atrophy, and Major Depressive Disorder. Review of Resident #9's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 15 indicating that the resident had no cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance to total assistance from the staff to complete the activities of daily living (ADL). Review of Resident #9's care plan titled ADL Self-care deficit related to physical limitations, finger contractures, weakness initiated on 10/25/2021 and revised on 09/08/23 documented an intervention initiated on 06/30/22 that read .Restorative Dressing/Grooming: Nail care Tuesday and Fridays day shift . Review of Resident #9's nursing progress notes from 08/20/23 to 10/18/23 lack documentation of Resident #9 refusal for nails grooming. On 10/16/23 11:13 AM, observation revealed Resident #9 was in bed and awake. Further observation revealed the resident's right hand little (pinky) fingernail approximately one (1) inch elongated and curled. The residents hands were contracted. Resident #9's left hand fingernails were elongated and dark matter was noted underneath the nails. Consequently, an interview was conducted with Resident #9 in Spanish who stated that his daughter cuts his fingernails. On 10/19/23 at 11:36 AM, an interview was conducted with the Unit Manager who stated that Resident #9 will only let the previous Unit Manager cut his fingernails. Subsequently, a side by side review of the resident's left and right hand fingernails was conducted with the Unit Manager. The Unit Manager stated definitely she will do the resident's nails today. During the review, an interview was conducted with Resident #9 in Spanish and he agreed with the Unit Manager cleaning and trimming his fingernails. 2. Resident #53 was admitted to the facility on [DATE] with diagnoses of Dementia, Kidney Disease, and Muscle wasting. The Quarterly Minimum Data Set, dated [DATE] showed a Brief Interview of Mental Status (BIMS) that the resident is severely cognitively impaired. In an observation conducted on 10/16/23 at 10:17 AM, Resident #53 was noted in bed vigorously scratching the back of his head and neck. Closer observation showed long and jagged fingernails. 105852 Page 4 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an observation conducted on 10/16/23 at 5:00 PM, Resident #53 was noted in bed vigorously scratching the back of his head and neck. Closer observation showed long and jagged fingernails. In a phone interview conducted on 10/16/23 at 10:39 AM, Resident #53's wife stated that she was at the facility last week and asked one of the staff members to trim Resident #53's fingernails. She was told that it would be done later after her visit. In this interview, she asked the Surveyor if they could ensure that Resident #53's fingernails were trimmed. The care plan initiated on 06/14/23 showed that Resident #53 has difficulty communicating related to a decline in cognitive status. In an observation conducted on 10/17/23 at 10:17 AM, Resident #53 was noted in a chair with long, jagged fingernails. In an observation conducted on 10/18/23 at 3:00 PM, Resident #53 was noted in a chair with long, jagged fingernails. In an observation conducted on 10/19/23 at 3:20 PM, Resident #53 was noted in a chair vigorously scratching the back of his head and neck. Closer observation showed long and jagged fingernails. In an interview conducted on 10/19/23 at 3:50 PM, Staff B, a Certified Nursing Assistant, stated that she cuts Resident's fingernails when she sees they need to be trimmed. When asked when she trimmed Resident #53's fingernails, she said that she did it when he moved to this unit a while ago. Surveyor asked staff B to accompany her to Resident's #53 room. After looking at Resident #53's fingernails, she agreed they needed to be trimmed. In an interview conducted on 10/19/23 at 3:00 PM, with the facility's Administrator, she was told of the findings. 105852 Page 5 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to follow Physicians ' orders for tube feeding for 1 of 2 residents reviewed for tube feeding, Resident #64. The findings included: Record review revealed that Resident #64 was admitted on [DATE] with diagnoses of Hypertension, Dysphagia, and Diabetes. The order summary report revealed an order for Glucerna 1.5 (tube feeding formula), infuse at 50 milliliters (ml) an hour over 20 hours from 4:00 PM to 12:00 PM, which was dated 10/06/23. In an observation conducted on 10/16/23 at 10:30 AM, Resident #64 was noted in bed with the tube feeding Glucerna 1.5 running at 50 ml an hour. Closer observation showed a tube feeding bottle at the 100 ml mark out of a 1000 ml capacity bottle. The date on the tube feeding bottle showed that it was started on 10/14/23, with no start time. In an observation conducted on 10/16/23 at 5:10 PM, Resident #64 was noted in her room with the tube feeding Glucerna 1.5 at 50 ml an hour, which started at 4:20 PM and was at the 1000 ml mark out of a 1000 ml bottle. Continued observation at 5:40 PM showed that the tube feeding mark was still at the 1000 ml level out of a 1000 ml capacity bottle. In an observation conducted on 10/17/23 at 9:12 AM, the tube feeding bottle, which started the day before on 10/16/23 at 4:20 PM, was noted at the 350 ml mark out of a 1000 ml capacity bottle. The tube feeding that started at 4:20 PM the day before should have been around 150 ml at the time of this observation. In an observation conducted on 10/17/23 at 11:20 AM, Resident #64 was noted in her room. Closer observation showed no tube feeding bottle infusing at this time. The Clinical Dietitian progress note dated 08/21/23 revealed that Resident #64 ' s estimated calorie needs were between 1225 to 1470 calories a day. The tube feeding Glucerna 1.5 running at 50 ml an hour provides 1500 calories a day if Resident #64 receives 50 ml of the tube feeding formulary in 20 hours. A weight observation on 10/18/23 at 5:00 PM showed a new weight of 100.6 lbs. The last recorded weight noted for Resident #64 was on 10/12/23 at 101.2. The care plan initiated on 06/29/23 showed the following: Resident #64 is at risk for malnutrition and to administer the tube feeding formula as per order. In an observation conducted on 10/19/23 at 10:00 AM, Resident #64 was noted in the room with the tube feeding running at 50 ml an hour, which was started on 10/18/23 (a day before) at 2:00 PM. The tube feeding was at the 400 ml mark out of a 1000 ml capacity bottle. This showed that only 600 ml of tube feeding formulary was infused in the last 20 hours. An interview conducted on 10/19/23 at 10:05 AM with Staff L, Licensed Practical Nurse, stated that 105852 Page 6 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0693 Level of Harm - Minimal harm or potential for actual harm Resident #64 was tolerating her tube feeding well. She further said that the tube feeding was already running when she came for her shift this morning. When asked by the Surveyor when should the tube feeding be stopped, she stated that she needed to look at Resident #64 ' s medical chart. Residents Affected - Few An interview conducted on 10/19/23 at 2:00 PM with the Clinical Dietitian stated that the tube feeding bottles provided in this facility are closed system bottles. The tube feeding bottle should have been discarded after 24 hours and not continued for 48 hours, as observed on 10/16/23. In an interview with the facility ' s Administrator on 10/19/23 at 3:00 PM, she was told of the findings. 105852 Page 7 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that a resident receiving dialysis was consistent with professional standards of practice, the comprehensive person-centered care plan, and the Resident ' s goals and preferences for 1 of 1 resident reviewed for dialysis (Resident #43). Residents Affected - Few The findings included: According to the State Operations Manual section §483.25(l), Dialysis, the communication process should include how the communication will occur, who is responsible for communicating, and where the communication and responses will be documented in the medical record, including but not limited to Nutritional/fluid management including documentation of weights, Resident compliance with food/fluid restrictions or the provision of meals before, during and after dialysis and monitoring intake and output measurements as ordered. Resident #43 was admitted to the facility on [DATE] with End Stage Renal Disease and Dependence on Renal Dialysis diagnoses. The order noted for a Renal (Dialysis) diet with regular texture and double protein with meals dated 09/19/23. Another order for dialysis three times a week was dated 02/22/22, and Glucerna (nutritional supplement) 2 times a day dated 09/08/23. In an interview conducted on 10/17/23 at 12:21 PM, Resident #43 stated that she was not on a fluid restriction per the Dietitian at the dialysis center and added that she could eat what she wanted. In an observation conducted on 10/17/23 at 5:30 PM, Resident #43 was in her room with the dinner meal. The meal ticket showed the following: Renal diet with double portions, fluid restriction of 946 milliliters (ml) a day, 8 ounces of milk, 4 ounces of apple juice, a bottle of Glucerna (nutritional shake), 6 ounces of tilapia (fish), and half a cup of green beans. Closer observation of the food items on the tray showed that Resident #43 received the following: 1 grilled cheese sandwich cut in half, half a cup of green beans, 4 ounces of apple juice, one bottle of Glucerna, 10 ounces of juice, and 8 ounces of water in Styrofoam cups near the dinner tray. The meal tray showed that Resident #43 had about 30 ounces of fluids (887 ml), which is almost the entire fluid needed for the day. In an observation conducted on 10/18/23 at 12:50 PM, Resident #43's lunch tray was noted with two slices of roast pork, green beans, and noodles. The meal ticket showed double entrée with two roast pork sandwiches. In this observation, the Surveyor asked the Kitchen Manager to take the weight of the roast pork served for Resident #43 using the facility ' s scale. Further observation showed that the weight of the roast pork was 3 ounces. The Kitchen Manager stated that the usual serving of roast pork for all residents was 2-3 ounces. When asked why Resident #42 did not receive a double portion of meat for lunch, he stated that he wanted Resident #43 to have more room for her nutritional supplements. Review of the Clinical Dietitian's progress note dated 09/19/23 showed the following: Resident #43 is on a regular diet of double protein, and she placed a call to the Dialysis Center Nurse to review the monthly labs and diet. On this note, the facility's Dietitian recommended putting Resident #43 on a 32-ounce fluid restriction and continuing with a renal diet with double portions. Interview with the facility's Clinical Dietitian on 10/18/23 at 2:57 PM, she stated that she has been working there since the middle of July of 2023. She said that Resident #43 was receiving double 105852 Page 8 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0698 Level of Harm - Minimal harm or potential for actual harm protein from her meals. When asked if Resident #43 was on a fluid restriction, she said yes and that it is about 940 ml of fluids a day with her meals. When the Surveyor asked why the fluid restriction was not in the order summary report, she stated that the fluid restriction was placed on the meal tracker and not on the orders because fluids were coming from the kitchen. The Clinical Dietitian reported that the Glucerna nutritional supplements are included in the total fluid restrictions for Resident #43 in the daily menu. Residents Affected - Few The care plan revised on 10/13/23 showed that the Resident needs Hemodialysis related to end-stage renal disease and to maintain fluid restriction as ordered. The nutritional part of the care plan modified on 09/07/23 showed that Resident #43 is on a fluid restriction of 32 ounces per Hemodialysis. Further review of the facility's meal tracker dated 11/26/23 for Resident #43 showed the following: for breakfast, it showed 8 ounces of milk, 4 ounces of apple juice, and 8 ounces of Glucerna, which totals 20 ounces of fluids for one meal. The dinner menu showed 8 ounces of milk, 4 ounces of apple juice, and 8 ounces of Glucerna, which totals 20 ounces of fluids for one meal. These two meals revealed a total of 40 ounces of fluids for two meals out of 3 meals for the day. In an interview with the facility's Administrator on 10/19/23 at 3:00 PM, she was told of the findings. 105852 Page 9 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure controlled medication were removed from the controlled box after the medication was discontinued for 2 of 6 sampled residents (Resident #33 and #74), and failed to obtain a physician order for a controlled medication removed from the controlled box for 1 of 6 sampled residents (Resident #33) reviewed during the controlled drugs record review at the facility's progressive units. The findings included: 1) Review of Resident #33's clinical record documented an admission on [DATE] with no readmissions. The resident diagnoses included Intervertebral Disc Degeneration, Lumbar Region, Senile Degeneration of Brain and Depressive Disorders. Review of Resident #33's active physician orders lack a written order for Oxycontin ( a controlled drug) ER 10 milligrams (mg) every morning for non-acute pain. Further review revealed Oxycontin drug was discontinued on 04/25/23. On 10/19/23 at 2:01 PM, a side by side review of Resident #33's Controlled Medication Utilization Record for Oxycontin ER 10 mg one tab every morning for non-acute pain, was conducted with Staff S, Licensed Practical Nurse (LPN). The review revealed the last Oxycontin 10 mg tablet removed from the controlled box was on 06/14/23 at 7:00 PM. During the review, Staff S stated that Resident #33's Oxycontin was discontinued and the medications should not be in the controlled box. Staff S was asked the facility's process related to discontinued controlled drugs and replied that the nurse had to remove it as soon as it is discontinued and give it to the Director of Nursing (DON). Review of Resident #33's June 2023's MAR (Medication Administration Record) lack evidence of Oxycontin 10 mg administration on 06/14/23 at 7:00 PM. The resident's clinical record lack evidence of a physician order for Oxycontin ER for the administration of Oxycontin on 06/14/23 at 7:00 PM. 2) Review of Resident #74's clinical record documented an admission on [DATE]. The resident diagnoses included Transient Ischemic Attack, Psychosis, Acute Renal Failure and Alcohol Abuse. Review of Resident #74's active physician orders lack a written order for Lorazepam ( a controlled drug) 1(one) mg one tablet three times daily as needed. Further review revealed Lorazepam medication was discontinued on 06/15/23. On 10/19/23 at 1:02 PM, a side by side review of Resident #74's Controlled Medication Utilization Record for Lorazepam 1(one) mg, one tablet three times daily as needed was conducted with Staff L, LPN. The review revealed the last Lorazepam 1(one) mg one tablet was removed from the controlled box on 07/13/23 at 2217 hours (10:17 PM). During the review, Staff L was asked for how long a controlled medication can be kept in the box if the resident did not have a physician order for it. Staff L replied that she was not sure how long it could be kept. On 10/19/23 at 3:56 PM, an interview was conducted with the DON and the Regional Nurse and were apprised of discontinued controlled medications kept in the controlled box without a physician order. The DON and the Regional Nurse were asked how long can controlled medications be kept in the box 105852 Page 10 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0755 without a physician order. The Regional Nurse stated that the controlled medication should be removed in one week. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105852 Page 11 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Resident #8 was admitted to the facility on [DATE] with diagnoses that included Atrial Fibrillation, Dementia with Behavioral Disturbances, and Major Depressive Disorder. Her Brief Interview for Mental Status was 7 per the quarterly Minimum Data Set with an assessment reference date of 08/04/23. This indicated the resident has a severe cognitive impairment. Residents Affected - Few A record review for gradual dose reductions was conducted on Resident #8. In June, 2023, the Consultant Pharmacist noted that the resident was taking Olanzapine Oral Tablet 5 Milligrams. This is an Antipsychotic medication that may be used to treat depression and agitation. Behavior monitoring was recommended for this medication but was not put on the Medication Administration Record until 10/17/23. An interview was conducted with the Consultant Pharmacist on 10/19/23 at 11:57 AM who stated that behavior monitoring should be done when a resident is taking this medication. Based on interviews and record review, the facility failed to monitor behaviors as per pharmacy recommendations for 3 of 5 residents reviewed for unnecessary medications (Residents #53, Resident #43, and Resident #8). The findings included: Review of the facility's policy titled Psychotropic Drug Use (no date) showed the following: The interdisciplinary team helps identify the behavioral target symptoms and specific behavioral concerns that warrant using an antipsychotic drug in the care plan intervention. 1. The customer's behavior is monitored. 2. The specific behavioral problems are tracked and documented as to the number of episodes or hours (iffor pacing, yelling, or screaming) as determined by the interdisciplinary team care plan. 1. Resident #53 was admitted to the facility on [DATE] with diagnoses of Dementia, Kidney Disease and Behavioral Disturbances. The Quarterly Minimum Data Set, dated [DATE] showed a Brief Interview of Mental Status (BIMS) that the resident is severely cognitively impaired. The order summary report showed an order for Quetiapine (an antipsychotic medication) at 50 milligrams at bedtime dated 06/12/23. Continued review of the order summary report revealed an order for behaviors - monitor the following: Restlessness (agitation), hitting, increase in complaints, spitting, cussing, racial slurs, elopements, psychosis, aggression, refusing care, and anger. Document: 'N' if none of the above is observed. 'Y' if any of the above was observed, which was only dated 10/16/23. Antipsychotic medications-monitor for dry mouth, constipation, blurred vision, confusion, difficulty urinating, hypotension, dark urine, yellow skin, drooling, tremors, disturbed gaits, increased agitation, involuntary movement, and document 'N' if none of the above is observed. 'Y' if any of the above was observed, which was only dated 10/16/23. Behaviors monitor for the following: Sad Affect, Continuous crying, withdrawal, and Mood Changes. Document: 'N' if none of the above is observed. 'Y' if any of the above was observed, which was only dated 10/16/23. Review of the Medication Administration Records did not show that Resident #53's behaviors for antipsychotic medication, which started on 06/12/23, were monitored before 10/16/23. The care plan dated 105852 Page 12 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0757 10/03/23 did not show that a care plan was initiated to monitor Resident #53's behaviors. Level of Harm - Minimal harm or potential for actual harm In an interview conducted on 10/18/23 at 10:50 AM with the Pharmacist Consultant, she stated that Resident #53 had been on antipsychotic medication since 06/12/23. She later identified that the facility's staff were not monitoring the behaviors of Resident #53. She then conducted an audit, and an order for behavior monitoring for the antipsychotic medication was written on 10/16/23, which was about four months later. When asked how important behavior monitoring is for residents who are on antipsychotic medications, she reported that it is very important. This is a way to know the effectiveness of the medication and if the residents need the specific dosages. Residents Affected - Few In an interview conducted on 10/18/23 at 11:05 AM, Staff D, Registered Nurse, stated that she was assigned to Resident #53 in the past and is currently his nurse for today. She said that she monitors his behavior and that it is documented in the Medication Administration Record (MAR). When asked if the behaviors were documented in the last few months in the MAR, she said yes. In an interview conducted on 10/19/23 at 3:00 PM with the Facility's Administrator, she acknowledged that the staff was not monitoring the behaviors of residents on antipsychotic medications. 2. Record review revealed that Resident #43 was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease and Depressive Disorders. The order summary report showed an order of Mirtazapine (medication for depression) 7.5 milligrams at bedtime dated 06/15/23. The Medication Administration Record for October 2023 showed an order for an Antidepression medication to monitor for sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremors, agitation, headache, and skin rash. It showed document 'Y' if monitored any of the above observed and selected a chart code which was dated 10/17/23. It further revealed an order to monitor the following: sad affect, continuous crying, seeming withdrawn, mood changes, and to document a 'Y' if watched any of the above observed and select a chart code, which was dated 10/17/23. The care plan that was initiated on 10/22/2021 showed that Resident #43 has indicators of depression and sadness, as evidenced by verbalization of sadness related to health conditions. Some of the interventions were shown to evaluate the effectiveness of the medications for possible decrease or elimination of the psychotropic drug. The facility Administrator acknowledged all findings in an interview conducted on 10/19/23 at 3:00 PM. 105852 Page 13 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the medication error rate was 7.69 percent. Two (2) medication errors were identified while observing a total of 26 opportunities, affecting Resident #36. Residents Affected - Few The findings included: Review of the facility's policy titled Administering Medications/ revised on 02/21/23 documented .medications are administered in accordance with prescriber orders, and current standards of practice .if a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident .the person preparing or administering the medication should contact the prescriber, the Attending Physician or the facility's Medical Director to discuss the concerns . Review of Resident #36's clinical record documented an admission on [DATE] and readmission on [DATE]. The resident diagnoses included Hypertension, Adult Failure to Thrive, Dementia, and Depressive Disorders. Review of Resident #36's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 8 indicating that the resident had moderate cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance from the staff to complete the activities of daily living. Review of Resident #'s care plan titled Cardia Disease related to Hypertension . initiated on 11/14/22 and revised on 10/03/23 documented an intervention that read administer medication per physician orders . Review of Resident #36's physician orders documented the following: -11/11/22- Propranolol HCl oral tablet 10 milligrams (mg), give 1 tablet by mouth one time a day for HTN (hypertension). Further review revealed the physician order did not include blood pressure parameters related to holding the medication. -11/12/22- Gavilax Powder (Polyethylene Glycol 3350) give 17 grams by mouth one time a day for constipation. Hold for loose stool. -11/11/22- Colace 100 mg, give one capsule two times a day for constipation. Hold for loose stools. -07/31/23- Divalproex Sodium tablet 500 mg by mouth two times a day for Dysthymia. -09/05/23- Fexofenadine 60 mg. give by mouth two times a day for Allergies. -10/12/23- Minocycline oral capsule 100 mg, give one capsule by mouth two times a day for skin infection. Review of Resident #36's October Medication Administration record (MAR) documented medications listed above were scheduled for administration daily at 9:00 AM. 105852 Page 14 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0759 On 10/18/23 at 9:23 AM, medication administration observation for Resident #36 performed by Staff D, Registered Nurse (RN) was conducted. Observation revealed Staff D poured the following medications: Level of Harm - Minimal harm or potential for actual harm -Stool Softener 100 mg one tablet Residents Affected - Few - Sertraline 50 mg- one tablet - Divalproex 250 mg-two tablets During the observation, Staff D stated that Resident #36 was scheduled to receive Propranolol 10 mg tablet but she was going to hold the medication due to the resident's blood pressure. Staff D stated the resident's blood pressure was 107/60 with a Pulse of 71. Staff D stated My critical judgment, as a nurse, if I give it to her (resident), her blood pressure may go too low. Staff D stated she would hold it, check on the resident during the day, and if she needs it, she will give it to her. On 10/19/23 at 9:01 AM, an interview was conducted with Staff D, RN. Staff D was asked if she contacted Resident #36's physician related to holding the resident's Propranolol on 10/18/23 and replied that she did not. Staff D added that she was told once to use her critical judgment. Staff D stated that she checked the resident's blood pressure later on the day and gave her the propranolol. Staff D was asked to submit documentation and she was unable to produce it. Staff D was apprised that she did not administer Gavilax Powder (Miralax) to Resident #36's on 10/18/23 during medication administration observation. Staff D stated Is prn (as needed) and sometimes the residents refused when they go to the bathroom. Staff D was asked why she documented it as given. Staff D replied that the computer was doing something weird. Staff D was apprised that she did not offer it and did not assess for loose stool during the medication administration observation with the surveyor. Consequently, a side by side review of the Resident #36's Octobers 2023 Medication Administration Record (MAR) for 10/18/23 was conducted with Staff D, RN. The review revealed that Staff D did not document medications administer to Resident #36 during medication observation on 10/18/23. Staff D stated she documented all medications given during the observation and did not know why it was not reflecting on the computer. On 10/19/23 at 10:38 AM, an interview was conducted with the Director of Nursing (DON) who was apprised of Resident #36's propranolol held on 10/18/23 during medication administration observation performed by Staff D. The DON stated that if the doctor does not give parameters to hold a medication, the nurses is supposed to give the medication, if the nurses has concerns, needs to call the doctor for orders. The DON stated that every morning she checks for missing medications administration and gives them to the Unit Managers for review. On 10/19/23 at 4:01 PM, the DON was apprised of medication administration observation errors. 105852 Page 15 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. 2) On 10/19/23 at 12:35 PM, a side by side review of the facility's 700 hall medication cart was conducted with Staff L, Licensed Practical Nurse (LPN). The review revealed an open bottle of Sodium Chloride tablets with an expiration date of 09/2023. Staff L stated she did not have any resident on that medication on her shift. Continued review revealed an opened Instant Oral Pain Relief gel tube with an expiration date of 08/2023. Staff L confirmed that the two medications were expired and that she was going to discard them. 3) On 10/19/23 at 12:44 PM, a side by side review of the facility's Progressive 2 unit's medication storage room was conducted with Staff L, LPN. Observation revealed one locked House Stock Nursing Office e-kit (emergency kit) on top of the counter and a list of medications behind the e-kit. Observation revealed multiple medications on the list with an expired date noted. Staff L was asked to open the House Stock Nursing Office e-kit (emergency kit) and stated she did not know how to do it. The Unit Manager was called in and instructed Staff L how to open the e-kit. The Unit Manager was apprised that the e-kit list documented expired medications. The Unit Manager stated that pharmacy brings a new e-kit daily. A side by side review of the e-kit was conducted with Staff L, LPN. The review revealed one House Stock Nursing Office e-kit (emergency kit) that contained the following medications with an expiration date of 09/23/23: -Three (3) Fluconazole (antibiotic) 100 milligrams (mg) -One (1) Epinephrine 1 mg/1 ml (millimeters) injection -Three (3) Furosemide (Lasix) 40 mg/1 ml vial During the review, an interview was conducted with Staff L, who stated that she will go to the sub-acute unit to get emergency medications as needed. Staff D added she had not used medications from the e-kit in the medication room. 4) Continuing side by side review with Staff L of a treatment cart parked in the medication storage room revealed an open bottle of Acetic Acid for wound care for Resident #3 dated 03/16 and another open bottle of Acetic Acid for wound care for Resident #1. Staff L stated that the Wound Care Nurse was the one responsible for the solutions in the treatment. On 10/19/23 at 1:40 PM, an interview was conducted with the facility's dedicated wound care nurse (WCN) who stated that Resident #3 and Resident #1 were no longer having wound care with Acetic Acid. The WCN stated that she did not use the treatment cart located in the units and added that she has her own treatment cart that she checks for expired supplies. 5) Continuing side by side review with Staff L of the medication storage room revealed a personal bag on top of the treatment cart located in the medication storage room in the Progressive Unit 2. The bag contained a personal bottle of water and more items inside the bag. Staff L stated that the bag belonged to Staff D, Registered Nurse. On 10/19/23 at 1:42 PM, an interview was conducted with Staff D, RN who confirmed her personal bag with a bottle of water in the Progressive 2 unit's medication room belonged to her. 105852 Page 16 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0761 Level of Harm - Minimal harm or potential for actual harm 6) On 10/19/23 at 1:43 PM, a side by side review of the facility's Progressive 1 unit's medication storage room was conducted with Staff D, RN. The review revealed a bottle of Melatonin and an opened bottle of Acetaminophen 500 mg/Benadryl 25 mg stashed in one of a multiple plastic compartments located in the room. Staff D stated they did not keep any over the counter medications in the medication storage room and added she went to central supply when she needed an over the counter medication. Residents Affected - Few On 10/19/23 at 3:56 PM, an interview was conducted with the Director of Nursing(DON) and the Regional Nurse and they were apprised of the findings. Based on observations, interviews, record reviews, and policy review, the facility failed to dispose of expired medications in 1 of 4 medications carts and in 2 of 2 medication storage rooms. The findings included: Review of the facility's policy titled Medication Storage, revealed the following: Policy: Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with Florida Department of Health guidelines. Procedure: Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. 1. A medication storage room observation in the facility's Subacute area was conducted on 10/19/23 at 1:30 PM with Staff O, Licensed Practical Nurse (LPN). While inspecting the medication room refrigerator, an observation was made of two small intravenous (IV) Sodium Chloride bags which had an expiration date of 10/15/23 (Photographic evidence obtained). Further observation revealed expired medical supplies including a clear/zipper plastic bag of 10 red-top blood collection tubes, a clear/zipper plastic bag of 12 purple-top blood collection tubes, 18 kits including injection site and cap, 6 IV catheters, 8 Tegaderm dressings, and 1 Kangaroo Y-Port/PEG Adapter (Photographic evidence obtained). An interview was conducted with Staff O regarding the expired supplies. She stated that she did not realize how many expired supplies were present and was not sure who was responsible for inspecting the storage rooms for expired medications and supplies. The unit manager was made aware of the expired supplies and medications. An interview was conducted on 10/19/23 at 4:00 PM, with Staff P, LPN, regarding the supplies kept in the medication storage room. Staff P stated that the residents' medications and supplies are kept in the storage room; and the staff should check if the supplies are expired or opened. 105852 Page 17 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide adaptive devices during dining as ordered by physician for 1 of 1 sampled residents for adaptive devices (Resident #49). Residents Affected - Few The findings included: Review of the facility's policy titled, Assistive Devices with a revised date of 09/2017 included: Assistive devices/utensils will be provided as identified in the individualized plan of care to maintain or improve a resident's ability to eat or drink independently. Record review for Resident #49 revealed the resident was originally admitted to facility on 08/30/23 with most recent readmission on [DATE]. The resident's diagnoses included: Metabolic Encephalopathy, Unspecified Dementia, and Muscle Wasting and Atrophy. Review of the Minimum Data Set (MDS) for Resident #49 dated 09/18/23 revealed in Section C, the Brief Interview of Mental Status was not conducted due to resident is rarely/never understood. In Section G revealed for bed mobility and transfer the resident had a self-performance of extensive assistance with support of two plus persons assist, for eating the resident has a self-performance of extensive assist with support of one person assist. Review of physician's orders for Resident #49 revealed an order dated 09/15/23 Health shake Sugar-Free (120ml/4oz per container) three times a day for nutrition support. Review of physician's order for Resident #49 revealed an order dated 10/06/23 for Regular diet Regular texture, Regular/Thin Liquids consistency. Review of physician's order for Resident #49 revealed an order dated 10/16/23 for Adaptive Equipment: Use two handled cup with spouted lid with meals. Review of the Care Plan for Resident #49 dated 08/31/23 with a focus on the resident has an ADL (Activities of daily Living) self-care performance deficit related to CHF (Congestive Heart Failure), AMS (Altered Mental Status), and impaired mobility. The goal was for the resident to improve the current level of function with ADLs through the review date. The interventions included: Adaptive Equipment: Use two handled cup with spouted lid with meals. PT/OT (Physical Therapy/Occupational Therapy) evaluation and treatment as per MD (Medical Doctor) orders. During an observation conducted on 10/16/23 at 9:55 AM of Resident #49 sitting in chair in her room with an empty 2 handled sippy cup on her overbed table in front of her and a second 2 handled sippy cup (also empty) on her bedside dresser. During an observation conducted on 10/16/23 at 12:15 PM of Resident #49 sitting in chair in her room with her daughter present. On the resident's overbed table was her lunch tray with a 2 handled cup with a brown lid with missing handles. The resident's daughter stated she had placed the apple juice in 1 of the 2 handled sippy cups the resident had in her room. When asked if the meal trays came with a 2 handled sippy cup for each beverage, she said she is not sure, she is not always here for the mealtimes, but today there was no 2 handled sippy cup on the tray, just a different type of 105852 Page 18 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0810 special cup. Level of Harm - Minimal harm or potential for actual harm During an observation conducted on 10/17/23 at 7:54 AM of Resident #49 resting in bed with eyes closed with a 2 handled sippy cup on overbed table. Residents Affected - Few During an observation conducted on 10/17/23 at 7:57 AM of Breakfast tray with milk and juice and no 2 handled sippy cup for Resident #49. The meal ticket listed adaptive equipment as 2 handled sippy cup. During an observation conducted on 10/17/23 at 8:20 AM of resident #49 sitting up in bed with a 2 handled sippy cup on the overbed table with a remanent of milk in the 2 handled sippy cup. During an interview conducted on 10/17/23 at 8:25 AM with Staff E Certified Nursing Assistant (CNA) who stated she has been working at the facility for 9 years. When asked about breakfast for Resident #49, she stated she fed the resident her breakfast already. When asked if the breakfast tray came with any 2 handled sippy cups, she stated no it did not. When asked how the resident drank her beverages of juice and milk, she stated after feeding the resident, she asked the resident if she wanted juice, which she did, so she took the 2 handled sippy cup to the pantry and washed it with hot water and put the juice in the 2 handled sippy cup. The CNA then stated after she finished the juice, she asked her if she wanted any milk, the resident said a little. The CNA stated she then took the 2 handled sippy cup to the pantry and washed it again with hot water, when she returned to the resident's room, she poured some milk in the 2 handled sippy cup. She removed the breakfast tray and was going to go back to the resident's room to get the 2 handled sippy cup to take it to the pantry again to wash it with hot water so she then could fill it with water. When asked if the resident wishes to have a sip of juice and then a sip of milk and there is only one 2 handled sippy cup, she said the resident has to drink the juice first, then she washes the 2 handled sippy cup and then pours the milk into the cup. The CNA then stated after the resident is finished with lunch, she will send the 2 handled sippy cup back to the kitchen on the lunch tray to be washed. When asked if the resident wants water after lunch and before her shift ends what does she do, she stated if the resident asks for water, she will go to the kitchen to get another 2 handled sippy cup. When asked if 2 handled sippy cups are sent to the resident on any meal trays, she said she does not know about dinner, because she is not here but sometimes, they send a 2 handled sippy cup on the meal tray but not always. During an observation conducted on 10/17/23 at 11:35 AM of Resident #49 receiving a lunch meal tray that included 4 ounces of juice and a carton house shake. There were no 2 handled sippy cups on the meal tray. The resident had a 2 handled sippy cup with ice water on her overbed table. The meal ticket listed adaptive equipment as 2 handled sippy cup. During an interview conducted on 10/17/23 at 11:40 AM with Staff E CNA who was asked about the 2 handled sippy cup for Resident #49, she acknowledged the kitchen did not send any 2 handled sippy cups with the meal tray, and the resident wants to keep her 2 handled sippy cup with ice water, so the nurse took her juice back to the kitchen to put it in a 2 handled sippy cup. During an interview conducted on 10/17/23 at 11:43 AM with Staff F Assistant Director of Nursing (ADON) who was asked about the 2 handled sippy cup for Resident #49, she stated the resident did not have a 2 handled sippy cup on the tray and she took the juice to the kitchen to put into a 2 handled sippy cup. When asked about the house shake in the carton, the ADON stated she will probably need another 2 handled sippy cup for the house shake. The ADON stated the kitchen should be sending a 2 handled sippy cup for each beverage. 105852 Page 19 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0810 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview conducted on 10/18/23 at 10:35 AM with the Dietary Manager (DM) who stated he has been working at the facility for 2 months. When asked if a resident has an order for 2 handled sippy cup, does the kitchen provide the 2 handled sippy cup on the meal tray, he said yes, we are supposed to. When asked if there should be a 2 handled sippy cup for each beverage on the meal tray, he said yes. When asked how many 2 handled sippy cups they have, he stated they have about 5-6 cups total. When asked how many residents use a 2 handled sippy cup, he said about 4-5 residents. The DM stated they identified they had a very low supply of the 2 handled sippy cups last week after being alerted by the speech therapist, and the 2 handled sippy cups are to be ordered. During an interview conducted on 10/18/23 at 10:45 AM with the District Dietary Manager, he stated he is going to a sister facility today to obtain more of the 2 handled sippy cups. 105852 Page 20 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0867 Level of Harm - Minimal harm or potential for actual harm Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interviews and recorded reviews, the facility failed to develop and implement a PIP (Performance Improvement Plan) in place regarding skin rashes that were monitored using systematic approaches. Residents Affected - Few The findings included: A review of the QAPI (Quality Assurance Performance Improvement) plan provided by the facility's Administrator revealed the following: PIPs are important and meaningful for the specific type and scope of services unique to the facility, which require a concentrated effort on a particular problem in one area of the facility. Our QAPI program will apply systems and reports demonstrating systematic identification, reporting, investigation, and analysis. A project charter will be developed for each PIP at the beginning of the project that clearly establishes the goals, scope, timing, and responsibilities. The PIP charter will be developed by the QAPI committee and then will be given to the team that will carry out the PIP. Review of the facility's policy titled Scabies Identification, Treatment, and Environmental Cleaning, dated 04/01/22, showed the following: during a scabies outbreak among residents, the Infection Preventionist or Committee will coordinate interdepartmental planning to facilitate a rapid and effective treatment program. In an interview with Staff G, Director of Nursing on 10/17/23 at 3:08 PM, she stated that they discussed scabies overall, under the infection control portion, in the QAPI meetings but could not provide any specific documentation regarding QAPI on scabies. In an interview conducted on 10/18/23 at 1:56 PM, Staff H, Infection Preventionist, stated that she brought the issue of scabies to the QAPI (Quality Assurance Performance Improvement) meetings. A QAPI on scabies was started and tracked, which they no longer have electronic access to view. According to her, the QAPI on scabies has been an ongoing issue addressed monthly in the QAPI meetings. She could not provide the documentation when asked if they conducted a scabies PIP with trending and tracking to include a list of all residents on the 600 and 700 units that were tested, with findings, treatments, and daily skin checks. In an interview conducted on 10/19/23 at 2:21 PM, the Administrator stated that she started effectively on 09/13/23. She was able to do her first QAPI meeting on September 21, and included infection control in that QAPI, but nothing specific to scabies. She was told by the Director of Nursing and Staff H regarding the skin issues. 105852 Page 21 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to maintain laundry equipment in a clean manner, store linens, and dispose of Personal Protective Equipment (PPE) in a manner to ensure infection control; and the facility failed to provide appropriate infection control surveillance related to scabies outbreak; the facility failed to practice hand hygiene during catheter care observation for 1 sampled resident for catheter care (Resident #67); the facility failed to maintain a sterile environment during trach care for 1 resident sampled for respiratory care (Resident #401). Residents Affected - Many The findings included: 1.) Review of the facility's policy titled, Surveillance -Infections with an effective date of 04/01/22 that included: The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infection (HAI), to guide appropriate interventions and to prevent future infections. Under Section General Guidelines included: The criteria for such infections are based on the current standard definitions of infection. Infections that should be included in routine surveillance included those with: Pathogens associated with serious outbreaks (e.g., invasive Streptococcus Group A, acute viral hepatitis, norovirus, scabies , and influenza). If transmission-based precautions or other preventative measures are implemented to slow or stop the spread of infection, the Infection Preventionist should collect data to help determine the effectiveness of such measures. When transmission of Healthcare-Associated Infections continues despite documented efforts to implement infection control and prevention measures, the appropriate state agency and/or a specialist in infection control and epidemiology should be consulted for further recommendations. In the section Gathering Surveillance Data included: The infection Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. The Infection Control Committee and/or QAPI Committee may be involved interpretation of the data. The surveillance should include a review of any or all of the following information to help identify possible indicators of infection: Laboratory records Skin care sheets Infection control rounds or interviews Verbal reports from staff Infection documentation records Temperature logs Pharmacy records Antibiotic review and Transfer log/summaries. 105852 Page 22 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Daily (as indicated): record detailed information about the resident and infection on an individual infection report form. 2.) Review of the facility's policy titled, Hand Hygiene with a revised date of 02/05/23 included: To prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. All staff should perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Referenced in the table for conditions and indication where hand hygiene is required listed under indication, before applying and after removing personal protective equipment (PPE), including gloves, use either soap and water or alcohol-based hand rub (ABHR) 60% or higher (ABHR is preferred). 3.) Review of the facility's Rash Investigation Report revealed the facility contacted the Department of Health (DOH) on 04/28/23 and there were no recommendations provided. The facility contacted DOH on 09/25/23, and recommendations were given. On 09/12/23 the pest control vendor did a room assessment for bed bugs that was negative (no indication which room(s) or units. In the Facility Intervention Log listed deep clean 05/16/23-05/17/23 with no notes, deep clean was also mentioned on 09/05/23 with a note that said deep clean to room of diagnosed patient, patient belongings and mattress bagged, mattress replaced. There was no indication which resident this was or what room they resided in. Again, a deep clean had a date of 09/18/23 with a note of deep cleaning to all carpeted room started on 09/18/23, all carpeted room are scheduled for deep cleaning of room and carpet. This did not identify which room numbers or when and/or if the deep cleaning was completed. There was a chart audit with a date of 05/25/23 with a note that documented last PRN (as needed) medication for itching used on 05/22/23 after deep cleaning, 64% of the affected patients have not had to use a PRN medication for itch/rash. There is no mention of which resident or their rooms. In the Patient Chart Audit list various resident with room number, date of intervention and date of intervention. For 12 out of the 16 residents listed had a comment about a diagnoses but with each time a resident was treated with a medication there was no comment. This indicated that the facility did not keep a comprehensive all-inclusive list in their Rash Investigation Report. Review of the line listing of residents who had been diagnosed with scabies included 4 residents. The first was listed as an onset date of 09/10/23, the second resident had an onset date of 09/19/23, the third resident had an onset date of 09/21/23, and the fourth resident had an onset date of 09/26/23. Review of a document provided by the Infection Preventionist (IP), revealed the outbreak of scabies was not reported in a timely manner to DOH (Department of Health). It was reported after the facility had a fourth resident with scabies, on 09/26/23. Review of the recommendations revealed the facility did not follow recommendations provided by DOH that included: Institute a system for conducting active daily surveillance of all patients, staff members, and visitors. Maintain a roster of suspected cases which includes names, location in the nursing home, date of onset of rash, treatment, current status and association with other cases prior to infestation. Clip the nails of the patients and clean carefully under the nails. 105852 Page 23 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview conducted on 10/17/23 at 4:15 PM with the contact person from the Department of Health, she stated she was informed by Staff H IP by email on 09/25/23 of an outbreak of scabies with 3 confirmed cases of residents residing in the facility. The contact from the Department of Health sent a form of recommendations for a scabies outbreak that included it is better for laundry not to be sent home for family members to do, all linens and personal clothing need to washed and dried using high heat, and any non-washable items should be kept in a plastic bag for a minimum of 72 hours. When asked when she last had contact with the facility in any way, she stated she had not heard any additional information from the facility. During an interview conducted on 10/18/23 at 8:20 AM with the in-house Dermatologist who was asked if he knows how to treat linens and personal clothing for resident with positive diagnosis of scabies, he said hot water but did not know how hot the water would be. He stated resident may be treated for scabies or suspect of scabies for a very long time. When asked if he could elaborate, he stated a post scabies rash may last 1-2 weeks and should start to subside after about 4 weeks. When asked if he placed any of the residents on contact isolation for having a positive diagnosis of scabies or residents suspected of having scabies, he said he does not, that would be up to the facility to follow their standard protocol for contact isolation. When asked if a resident is diagnosed as have scabies should they be placed on contact isolation, he said yes. When asked if residents being treated prophylactically for scabies should be on contact isolation, he said that is up to the facility's standard protocol, I am sure they have one. When asked if he knew how many residents were treated prophylactically for scabies or diagnosed as having scabies, he said he does not keep track of that, all documentation should be in each resident's medical record. When asked if he had given the facility or the IP, or DON any recommendation for treating or preventing scabies he said no. When asked if he checked all resident in the affected wings with scabies outbreak or suspected scabies, he said he is not sure, all documentation would be for each resident in their individual medical record. During an interview conducted on 10/18/23 at 2:00 PM with Staff H, Infection Preventionist (IP) PRN (as needed) who stated she works remotely now, and she was the IP full time on site for 9 months before she went PRN on 09/30/23. Also present during the interview was Staff G, Director of Nursing/Infection Preventionist (DON/IP). Staff H said she was doing all monitoring/reporting for any infections such as covid or scabies only until she went PRN, she continues to do the reporting but no longer does the monitoring since she went PRN on 09/30/23. When Staff G and Staff H were asked about the outbreak of scabies, Staff H stated around March they received complaints from some of the patients they were itching and having a rash. All of the patients with the itching and rash were on the long-term care side of the building. Staff H stated she in April she had contacted the Department of Health (DOH) for any suggestions or recommendations but did not get any suggestions or recommendations at that time. Staff H stated they consulted the in-house Dermatologist who diagnosed the affected residents as having Contact Dermatitis. Staff H stated the in-house Dermatologist performed scraping for about 80% of the affected residents or who he thought might have scabies. Staff H stated that some of the family members took some of those affected residents to an outside dermatologist due to the unresolved itching/rash. The DON/IP stated the facility helped the families to arrange for the appointments and the transportation to the outside dermatologist for a second opinion. Staff H and the DON/IP stated in April they had also had their pest control vendor come into the facility to do an inspection of the facility for any pest and were unable to find any bedbugs. The pest control vendor recommended to do a deep cleaning of carpet and furniture. At this time, they also had the maintenance department look into the air filters and they verified with the housekeeping department there had been no change in the detergents used. For the residents 105852 Page 24 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many affected with the itching/rash that were having their laundry washed by family, they checked with the family members about any change in detergent and most families stated they had not changed laundry detergent and or used sensitive type detergent. They stated they would notify the in-house Dermatologist with a list of residents who were complaining of itching or had a rash, and the in-house dermatologist did a biopsy on some of those residents. When asked since the residents continued with itching/rash and more residents were complaining of itching/rash, did they check all residents on the long-term care side of the building for itching/rash, the DON/IP stated she thinks every resident gets a weekly skin check. When Staff G and Staff H were asked if they were keeping any sort of surveillance on the residents on the long-term care side building, they stated they started a timeline. Staff G stated she updated the timeline monthly but may not include follow ups by dermatology, or all biopsies, treatment for rash/itching and if conditions improve worsen or resolved. When asked when the first resident was diagnosed with scabies, Staff H said it was on 09/10/23. She stated they an additional resident test positive for scabies on 09/19/23, again on 09/21/23 and again on 09/26/23. She said each resident who was positive for scabies was placed on contact isolation and treated prophylactically and if any of the residents who tested positive for scabies had a roommate the roommate would have been treated prophylactically and also placed on contact isolation. When asked when they placed residents on contact isolation, Staff G stated immediately when the biopsy came back positive, and they were on contact isolation until after 24 hours after treatment. She also stated any resident who was being treated prophylactically, all linens and clothing were cleaned in house and all of the family members of positive residents were made aware that the resident was positive for scabies or being treated prophylactically. Staff H stated on 09/26/23 she contacted DOH to report an outbreak of scabies and received recommendations for an outbreak of scabies. When asked if they followed the recommendations from the DOH for a scabies outbreak, Staff G said yes, they did. When Staff G was asked if that included instituting a system for conducting active daily surveillance of residents, staff members, and visitors, she said no. The DON/IP stated we do weekly skin checks for residents. When asked if they maintain a roster of suspected cases which includes names, location in the nursing home, date of onset of rash, treatment, current status and association with other cases prior to infestation, they said they just have the line listing that they sent to DOH with the 4 residents who were positive for scabies. 4.) During a tour of the laundry room conducted on 10/16/23 at 2:00 PM with the Director of Housekeeping (DOH) and the Director of Maintenance (DOM) the following observations were made: a) In the washer/dryer laundry room the handwashing sink was dirty, had a kitchen utensil in the basin, basin surface was crumbling (Photographic evidence obtained). b) In the washer/dryer laundry room the trash container was overflowing with garbage and used personal protective equipment (Photographic evidence obtained). c) In the washer/dryer laundry room the personal use washing machine inside tub was rusted (Photographic evidence obtained). d) 105852 Page 25 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many In the washer/dryer laundry room the wheeled red transport bin had personal clothing and a used disposable glove all uncovered (Photographic evidence obtained). e) In the washer/dryer laundry room the wheeled wire cart had personal items in a mesh bag, privacy curtains, and a mechanical lift sling all uncovered (Photographic evidence obtained). f) In the laundry folding room the wheeled red transport bin contained uncovered hospital gowns and linens (Photographic evidence obtained). g) In the laundry folding room the table had uncovered folded laundry (Photographic evidence obtained). During an interview conducted on 10/16/23 at 2:30 PM with the Department of Housekeeping, who when asked if the laundry items (linens and personal items) should be left out uncovered, he said it is ok. When asked if laundry items should be left in bins or carts uncovered, he said he will take the items out, they are to be washed or folded. He stated the personal washing machine is not used, and 1 of the 3 commercial washers has been broken and is no longer used. When asked about the trash bin overflowing with used PPE, he said it just needs to be emptied. 5.) Record review for Resident #67 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Obstructive and Reflux Uropathy. Review of the Minimum Data Set (MDS) for Resident #67 dated 10/04/23 revealed in Section C the resident had a Brief Interview of Mental Status score of 11, indicating moderate cognitive impairment. Review of the Physician's orders for Resident #67 revealed an order dated 09/29/23 for foley catheter 16FR/10cc normal saline, diagnoses Obstructive Uropathy, drain and record output. Review of the Physician's orders for Resident #67 revealed an order dated 09/29/23 for foley catheter care with soap and water every shift and as needed. Review of the Care Plan for Resident #67 dated 09/30/23 with a focus on resident has indwelling catheter related to diagnosis of Obstructive Uropathy. The goal was for the resident to show no signs/symptoms of urinary infection through review date and for the resident to be/remain free from catheter related trauma through review date. The interventions included: Provide catheter care as ordered. On 10/16/23 at 11:44 AM an observation was made of Resident # 67 lying in bed and indwelling catheter drainage bag with privacy cover hanging from bed frame. On 10/18/23 at 11:05 AM an observation was made of indwelling catheter care for Resident #67 performed by Staff E Certified Nursing Assistant (CNA). The CNA gathered supplies, washed hands, applied gloves, cleaned the resident's penis, scrotum, and catheter, and removed her gloves 6 times and applied new gloves. For 3 out of the 6 times the CNA changed her gloves she did not perform hand hygiene 105852 Page 26 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0880 (either washing with soap and water or using alcohol-based hand rub). Level of Harm - Minimal harm or potential for actual harm During an interview conducted on 10/18/23 at 11:35 AM with Staff E CNA who stated she has worked at the facility for 9 years. When asked about hand hygiene between gloves being changed, she stated she knew she forgot to use hand sanitizer a couple of times. She stated she is supposed to either wash her hands or use hand sanitizer when she removes her gloves before she puts new gloves on. Residents Affected - Many 6.) Review of the facility's policy titled, Nursing-Tracheostomy Care, dated 04/01/22, included the following: The purpose of this procedure is to guide tracheostomy care and cleaning of reusable tracheostomy cannulas. Equipment and Supplies: Gloves (clean and sterile). General Guidelines: Aseptic technique must be used: During tracheostomy tube changes, either reusable or disposable. Gloves must be used on both hands during any or all manipulation of the tracheostomy. Sterile gloves must be used during aseptic procedures. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be always available at the bedside. Clean the Removable Inner Cannula: Open tracheostomy cleaning kit. Set up supplies on sterile field. Maintaining sterile field. Put on sterile gloves. Secure the outer neck plate with non-dominate gloved hand. Unlock the inner cannula with gloved dominate hand. Gentle remove the inner cannula. A tracheostomy care observation was conducted on 10/18/23 at 4:52 PM with Staff N, Licensed Practical Nurse (LPN) for Resident #401. Staff N introduced herself to Resident #401 and advised that she was going to perform tracheostomy care. Staff N closed the room door for privacy. She washed her hands, donned clean gloves, and cleaned the bedside tabletop. She removed the gloves, discarded, used hand sanitizer, and donned clean gloves. She then gathered the following supplies: one tracheostomy cleaning kit, normal saline tubes (4), disposable inner cannula (1), hand sanitizer, extra gauze dressing and a suction catheter kit (the suction machine was already present in the room). Staff N opened the tracheostomy care kit and set up the sterile field on the cleaned bedside table. She carefully opened a paper/plastic container and poured the four normal saline tubes into it. She then carefully opened the disposable inner cannula package and dropped the inner cannula onto the sterile field. She then removed her gloves, discarded, used hand sanitizer, and donned clean gloves. She moved the 105852 Page 27 of 28 105852 10/19/2023 Boca Circle Rehabilitation Center 7225 Boca Del Mar Drive Boca Raton, FL 33433

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many supplemental oxygen mask to the side of the tracheostomy prior to removing the inner cannula. She mentioned that since it is a disposable cannula, it does not need to be cleaned and it will be thrown away. She then removed the old tracheostomy dressing. She removed her gloves, discarded, used hand sanitizer, and donned clean gloves. She placed 2 sterile cotton-tipped applicators in the container of normal saline. She then used one cotton-tipped applicator and cleaned the left-side of the tracheostomy outer neck plate and discarded; she then used the other cotton-tipped applicator and cleaned the right-side of the tracheostomy outer neck plate and discarded. She removed her gloves and discarded, used hand sanitizer, and donned clean gloves, placed 4 gauze pads in the saline solution. Then, she picked up 2 gauze pads and cleaned the outer right area of the tracheostomy tube, discarded, then picked up the other 2 gauze pads and cleaned outer left area of the tracheostomy tube and discarded. She removed her gloves, discarded, used hand sanitizer, donned clean gloves, and inserted the new disposable inner cannula into the tracheostomy. She soaked 4 gauze pads in the normal saline container; used 2 gauze pads to clean each side of the stoma, using a single sweep for each side. She then wiped the stoma with dry gauze, using a single sweep for each side. She removed her gloves, discarded, used hand sanitizer, and donned clean gloves. She then applied the fenestrated gauze pad around the tracheostomy insertion site and replaced the supplemental oxygen mask over the tracheostomy site. She then removed her gloves, discarded, and washed her hands. An interview was conducted with Staff N following the procedure. The surveyor asked, if there are sterile gloves included in the tracheostomy kit, when would you use the sterile gloves during the care? Staff N responded that she would use it during suctioning. She then stated that she was not sure when she would use the sterile gloves. On 10/19/23, the areas of concern regarding the tracheostomy care for Resident #401 were discussed with the Director of Nursing and the unit manager. 105852 Page 28 of 28